Congratulations! You're pregnant. You are now wondering how to create the best possible environment for you and your baby, and the environment that you have the most control over is your mental one. It is important that you have a good inner opinion of yourself during pregnancy. Rest assured that your body is already equipped for the challenges of pregnancy and birth. You can educate your mind, develop trust in your body, and fortify your spirit with accurate and objective information. And you can trust yourself to act in your own best interests and in the best interests of your child.

With pregnancy, you may be surprised to find how deeply your choices have been influenced by the beliefs, attitudes, and customs of society, by the opinions of family members, and by your general lack of exposure to birth. Unless you have witnessed them, pregnancy and birth can seem strange and frightening when in fact they are simple and natural. Several factors contribute to our collective belief that pregnancy and birth are complicated. The overmedicalization of childbirth in the United States, the human tendency to be intimidated by custom and authority, and the fact that insurance companies often only cover hospital birth make real choices in childbirth difficult if not impossible.

In 1982 psychiatrist Ronald Laing wrote, "We do not see childbirth in many obstetric units now. What we see resembles childbirth as much as artificial insemination resembles sexual intercourse. And, birth, as a home and family event, has virtually been cultured out." Laing believed this change was a matter of power. "Women are allowed or not to have their babies at home. In hospital, they are allowed or not to move, scream or sing, stand, walk, sit or squat. Women are allowed or not to have their babies after birth....To allow is to exercise as much, if not more power, than to forbid." Laing pleaded for genuine choice, asking, "Why should any one way have to be imposed on all? Why cannot two or more ways coexist in the same society? Why should there be any monopoly on what is available?"

Understanding Your Choices: Informed Consent

Pregnancy and birth are normal biological events. They are not medical events, but they take place within a cultural context and are colored by the beliefs and attitudes of the community at large. Hopefully, this book will give you a bigger sense of these events as they occur in this larger community, and help you to find the information and support you need to plan for your own birth environment and the arrival of your new baby.

You deserve to have true informed consent regarding the decisions you make during this time. While it sounds like a fancy term, informed consent simply means that you have the right to know the risks and benefits of treatment, and the right to choose which procedures you want during pregnancy and birth, regardless of how commonly they are used. All too often, we undergo procedures passively, without being aware that we could question or even decline a treatment.

Informed consent has been a legal principle for 100 years in the United States. This doctrine requires practitioners to disclose all information needed to make a decision, and requires that consent be given voluntarily and without coercion. The concept of informed consent is critical: in thousands of letters to Mothering magazine, women have said that they regret that they had not known more about their choices during pregnancy and birth.

The advice and suggestions in this book are based not only on scientific evidence but on the experiences of these women who have come to trust Mothering magazine as a respected authority on natural family living.

About Our Sources

Mothers-to-be are often confused by the conflicting medical literature that is available. For example, guests on talk shows routinely quote contradictory findings to prove a specific point. In addition, practices in common use are not always supported by medical research. As a pregnant woman, you will want to look carefully at the evidence, so I have sought out a definitive and objective resource.

The recommendations in this book are based on Oxford University's Effective Care in Pregnancy and Childbirth, a 1,500-page, two-volume book that summarizes the most authoritative international studies available on the effects of care practices during pregnancy, during childbirth, and after the baby is born. The first edition, published in 1989, was widely acclaimed as a landmark publication. For the first time, evidence-based information on the effects of pregnancy and childbirth care was made readable and accessible to all who needed and wanted it.

The second edition won first prize in the British Medical Association 1995 Medical Book Competition in the Primary Health Care category, and has been translated into several languages. The third edition of this book was prepared by the editors of the Cochrane Pregnancy and Childbirth Group, along with Murray W. Enkin, M.D., a prominent physician and author of the first edition.

Effective Care in Pregnancy and Childbirth has been compiled into an electronic database consisting of a register of over 9,000 controlled studies from almost 400 medical journals, in 18 different languages, from 85 different countries -- as well as a systematic review of their results. The suggestions here are based on the latest, most comprehensive scientific evidence, providing you with the most up-to-date information on which to compare choices for yourself during pregnancy and childbirth.

Why Natural?

As the title implies, this book focuses on natural pregnancy and childbirth, subjects Mothering magazine has been reporting on for over twenty-five years. During that time, we've learned that women who experience natural childbirth not only report greater satisfaction with their birth experiences than those who do not, but also feel less pain and discomfort during the early weeks and months of motherhood. It is unfortunate, therefore, that these concepts have been misunderstood in recent years. For instance, some consider a birth "natural" simply if the mother is conscious, while others, more accurately, understand that a natural childbirth is a drug-free birth. Even more unfortunate is the fact that so few women are helped and encouraged to have a natural birth.

You may be frightened when the subject turns to drugs in labor and wonder if natural birth means that your choices will be limited. Some of you would hate to have drugs foisted on you; others want to make sure that you have access to the comfort level of your choice. In pregnancy and birth, what you want is simply choice. And yet you may not realize how much your choices are limited by the constructed culture of birth, by custom unsupported by evidence, and by our general lack of exposure to and discomfort with birth. For example, most women will experience ultrasound scans during their pregnancies, even though ultrasound is not recommended for routine use by the American College of Obstetricians and Gynecologists. Electronic fetal monitors are routinely used in hospital birth, yet they have never been shown in scientific studies to be any more effective than a simple stethoscope. And it may surprise you to learn that birth is safe in any setting -- home, hospital, birth center -- although only 1 percent of births in the United States take place outside of a hospital.

Twenty-three other countries have better birth outcomes than we do in the United States. All of these countries spend less money on health care than we do. Even with all of our technology, we are not protecting as many babies and mothers as other countries do with less. American insurance companies define pregnancy as a disability; obstetrical medicine acts defensively to ward off malpractice suits; pharmaceutical companies and manufacturers of birth technology entice practitioners to try their products by offering incentives; in short, as a culture, we are uncomfortable with the intimate physical events of pregnancy, birth, and breastfeeding.

What do those twenty-three countries have in common -- those who spend less money yet have better birth outcomes than the United States? All of them rely on midwives. In New Zealand, for example, midwives attend 70 percent of births. In the United States, midwives attend nearly 10 percent of births.

Compare these labor and delivery outcomes for low-risk mothers who were clients of certified nurse-midwives (CNMs) with the clients of physicians (M.D.s):

Labor and Delivery ProcedureCNMsM.D.s

Oxytocin induction* 8.5% 15.2%

Oxytocin augmentation** 11.7% 37.2%

Internal electronic fetal monitor 16.2% 43.5%

Epidural anesthesia 17.3% 32.7%

Episiotomies 10.8% 35.4%

Third- and fourth-degree lacerations*** 6.6% 23.3%

Operative deliveries**** 11.0% 30.1%

* Oxytocin induction is the use of the drug oxytocin to attempt to end pregnancy and stimulate labor to begin.

** Oxytocin augmentation is the use of oxytocin to attempt to increase the strength or effectiveness of labor contractions.

*** Third- and fourth-degree lacerations are tears of the perineum, usually following an episiotomy, that extend into the rectum.

**** Operative deliveries include those delivered by vacuum extraction, forceps, or cesarean section

The Institutes of Medicine, the Office of Technology Assessment of the U.S. Congress, and the National Commission to Prevent Infant Mortality have all published statements of support for the development of nurse midwifery in the United States. In 1989, the National Birth Center Study was published in the New England Journal of Medicine, a study that demonstrated positive results of care of 12,000 birthing women by certified nurse midwives. The study showed that compared to hospital births, birth center births had a lower risk of cesareans, less infant death, and no maternal death.

More Evidence for Natural Birth

In her 1990 book Safer Childbirth, British statistician Marjorie Tew published overwhelming evidence for the safety and superiority of skillful midwifery and home birth. In fact, no study of matched populations has ever shown home birth to be unsafe.

In a report published in March 1992, the British House of Commons stated, "We conclude that the choices of a homebirth or birth in small maternity units are options which have been substantially withdrawn from the majority of women in this country....The policy of encouraging all women to give birth in hospitals cannot be justified on the grounds of safety....Hospitals are not the appropriate place to care for healthy women."

A 1998 National Institutes of Health study published in the Journal of Epidemiology and Community Health found that patients of certified nurse midwives have 19 percent lower infant mortality rates than doctors, 31 percent less neonatal mortality, and 33 percent less incidence of low birth weight.

A 1999 Stanford University dissertation by Peter F. Schlenzka provided even more evidence of the safety of natural childbirth. He examined nearly 816,000 births from 1989 and 1990, comparing both low-risk and high-risk births occurring both at home and at the hospital. Schlenzka found no difference in mortality rates for infants born in the hospital or in other settings. His findings clearly show that the natural approach is as safe for both groups.

In California, Santa Cruz County has cited Schlenzka's research as the basis for ballot initiatives calling for expanded birth services for local residents. The county's December 2000 Strategic Plan called for adopting the goals of the "Mother Friendly Childbirth Initiative," a document defining ten prerequisites for a mother-friendly birthing environment; making midwifery care available at the local hospital; providing every pregnant woman with a "Midwifery Model of Care" brochure; funding development of a freestanding birth center; ensuring financial support for women who desire out-of-hospital birth; and awarding grants to helping services and nonprofits. These initiatives are significant because they mark the first time a county government has recommendedalternatives to hospital birth.

The History of Childbirth

If midwifery care and natural birth are actually safer and more satisfying, why are they not more popular? To answer this question, it is important to understand the cultural context, which determines to a large extent both our choices and our experiences regarding pregnancy and childbirth. For nearly 200 years, midwives, physicians, and nurses have competed in one way or another to be the main care providers for pregnant and birthing women. The enduring influences of this competition have affected our choices regarding place of birth, birth attendant, birth interventions, and pain management, as well as physical contact with our babies, breastfeeding, postpartum care, and early family life.

Early Midwives and Obstetricians

Not until the Revolutionary War did educated doctors seek to attend births. Before then, physicians regarded care of the pregnant woman as beneath their dignity and expertise. In addition, childbirth was viewed as a life-threatening event that could result in death, regardless of who attended the birth. Midwifery was not considered part of medicine, and the few men who did attempt to practice midwifery were widely ridiculed for their intrusion into an exclusively female profession. Midwives were generally women who had birthed several of their own children, and had learned by assisting at friends' births or learning from an established midwife. Organized training programs and schools for midwives did not exist until 1848, when the Boston Female Medical College opened in the United States.

Midwives were often the only source of health care, and they were respected members of the community. Many came as colonists, some as slaves, and others as immigrants. While some had received training in other countries, learning was most often passed on through the apprenticeship method, and yet most midwives were isolated from one another, busy with their own families, and did not think of themselves as members of a profession.

With the development of obstetrical forceps in the 1750s in England, obstetrical practices began to change rather dramatically, both in England and subsequently in the United States. Midwives who had maintained an unquestioned monopoly found themselves in competition with male practitioners -- now claiming to have superior knowledge in the form of obstetrical instruments.

At first, physicians were only called to assist at difficult births, but gradually it became more common for forceps to be used to hasten the process of normal delivery. By the early 1800s, it was popular for upper- and middle-class women to have forceps deliveries with male physicians.

By the mid-1800s, medicine was becoming professionalized: the American Medical Association, founded in 1847, recognized obstetrics as one of its four special sections as early as 1859. By 1888, the American Association of Obstetricians and Gynecologists was formed. Physicians sought legislation that would create state licensing requirements allowing only physicians to practice medicine.

Unfortunately, there was no effort at that time to educate and license midwives. Midwifery practices were diverse, and laws were mainly local. In fact, it was not until the 1920s that most midwives practiced under some type of regulation. By that time, there were not enough schools to certify professional midwives in sufficient numbers.

By 1900, physicians were attending about 50 percent of all births in the United States, and virtually 100 percent of the births of middle- and upper-class women. Midwives primarily took care of poor women. At this time, misguided advocates for women, including female physicians, male obstetricians, and others, demanded the abolition of midwifery, claiming that it was unsafe. They called for the prohibition of midwives, especially in areas where doctors were available.

In the years to come, midwives were systematically outlawed as state after state succumbed to intense medical pressure. Meanwhile, in England, Germany and most European nations, midwives were trained to become established and independent practitioners.

The Rise of Medical Birth

The struggle between midwife and physician for dominance in the care of pregnant and birthing women peaked between 1910 and 1935. The Carnegie Foundation's 1910 Flexner Report focused on medical education in the United States in general and found it to be of poor overall quality, with obstetrics making the worst showing. The report concluded that medical progress required obstetric physicians to take over the supervision of childbirth, adding that there was not enough time to educate and certify midwives.

The prejudices of the time supported this view, and the most influential obstetricians publicly participated in the defamation of midwives as untrained and therefore unsafe. The 50 percent of births still attended by midwives were seen as a missed opportunity for obstetrical training.

In addition, experts of the early 1900s argued that childbirth was a dangerous condition that damaged most women and warranted routine medical intervention. In fact, they believed that forceps delivery was safer than unassisted labor, which was assumed to hinder a woman's sexual functioning and possibly damage her baby's brain. The campaign to eliminate midwives was part of the attempt by obstetricians to establish the credibility of their own fledgling profession.

The 1900s saw the beginning of the American migration to cities, the development of the modern hospital, and the rise of allopathic, or Western, medicine. By 1939, the use of sterile techniques and the development of antibiotics improved the safety of birth, particularly in hospitals, where infections after childbirth were common.

In addition, economic factors made hospital birth more acceptable. Prior to the 1930s, individuals paid for all of their own medical expenses. The Great Depression spurred the creation, in 1943, of the Emergency Maternity and Infant Care (EMIC) program, which eventually provided free hospital obstetric care to over a million mothers and babies. Within three years, it covered one of every seven births in the United States, and therefore made hospital birth affordable. By the late 1940s, half of all births took place in the hospital.

In the 1940s, the "modern way" to give birth was under total anesthesia. "Twilight sleep," the method of choice, involved injecting a laboring woman with morphine and then giving her the amnesiac, or memory-impairing, drug scopolamine. At the time, the development of twilight sleep was hailed as a breakthrough, although the birthing woman was so drugged that she could seldom participate in the birth, requiring multiple interventions such as episiotomies and forceps delivery.

By 1960, nearly all women gave birth in the hospital. Over 90 percent of white women and 74 percent of African-American women were anesthetized during delivery. Eventually it was recognized that morphine contributed to maternal deaths, that scopolamine didn't actually kill pain (only the memory of pain), and that general anesthesia depressed the mother's as well as the baby's respiratory and nervous system. Sadly, home birth had virtually been eradicated by the mid-1970s, and 99 percent of births took place in the hospital.

Natural Childbirth Is Reborn

Counter to this increased medicalization of childbirth were two breakthroughs. One was the 1944 publication of Grantly Dick-Read's book Childbirth without Fear: The Principles and Practice of Natural Childbirth, a book that discussed for the first time in the popular press the role that emotions play in birth. Dick-Read, a British obstetrician, proposed the then-novel idea that fearing the pain of labor increases the pain of labor. Dick-Read concluded that educating women about childbirth could prepare them to withstand its rigors. Dick-Read became the first to advocate the use of controlled breathing and relaxation techniques during labor. Results with the Dick-Read method at Yale New Haven Hospital Clinic in 1946 showed that women who were educated in breathing and relaxation techniques used less medication than unprepared women.

The second breakthrough came in 1951 when two French obstetricians, Fernand Lamaze and Pierre Vellay, traveled to Russia to observe the so-called psychoprophylactic (mind-over-matter) obstetrical practices in use there. In 1956 Painless Childbirth, Lamaze's classic book on this practice, was published. His method relied heavily on the use of distraction techniques during contractions. The most famous of these techniques involves structured, controlled breathing.

In 1960 Elisabeth Bing, a physical therapist, and Marjorie Karmel, a mother who had trained with Dr. Lamaze while pregnant in France, introduced and popularized this technique as "the Lamaze method" in the United States.

Significant Strides

Meanwhile, despite persecution from obstetricians, midwifery care continued to evolve. In 1911, amid studies that concluded that mothers and babies in the United States were dying more often than they were in many western European countries, the commissioner of health for New York City criticized the United States as being the only "civilized" country in the world that did not safeguard the care of mothers and babies by training and regulating midwives.

In 1918 the Maternity Center Association, the first woman-centered birthing organization in the United States, created the nation's first prenatal-care pilot project, as well as another significant first -- classes for expectant parents. A report on the association's first twenty years of operation appeared in 1955 in the American Journal of Obstetrics and Gynecology. Of 5,000 births attended by association midwives, 87 percent took place in the home. Women cared for by these midwives were nearly three times less likely to die in childbirth than the average woman, who typically gave birth in a hospital setting without a midwife present.

In 1925 Mary Breckenridge, a British-trained midwife, established the Frontier Nursing Service in the Appalachian Mountains of southeastern Kentucky, creating a new model for rural health care and sowing the seeds of nurse-midwifery. Sixteen graduates of the Frontier Nursing Service formed the first nurse-midwifery organization in the United States, the Kentucky Association of Midwives, in 1929. This group went on to become the American Association of Nurse-Midwives, originally affiliated with the National Organization for Public Health Nursing, and later established as the American College of Nurse-Midwives.

Voices of a New Generation

In the 1960s the voices of pregnant and birthing women began to be heard. In 1960, the International Childbirth Education Association was founded to promote family-centered maternity care and freedom of choice based on knowledge of alternatives. Sheila Kitzinger's revolutionary book The Experience of Childbirth, published in 1962, introduced the idea that birth is a highly personal event. She recommended that labor pains be accepted as "pain with a purpose."

In 1965 Robert Bradley, M.D., published Husband Coached Childbirth, adding American innovations to the Dick-Read relaxation and breathing methods. Bradley especially encouraged husbands to participate as coaches during the birth process. It was not until the 1970s, however, that fathers were actually "allowed" in the delivery room with mothers.

Birth activism came of age in the 1970s, with the publication of three landmark books: Doris Haire's Cultural Warping of Childbirth; Suzanne Arms's Immaculate Deception; and Ina May Gaskin's Spiritual Midwifery. In 1976, Mothering magazine was founded as a voice of this activism. The Seattle Midwifery School opened in 1978 as the first modern midwifery school in the United States that did not require a nursing degree for admittance.

That same year the cesarean section rate for the United States hit 18 percent; it was 7 percent in 1960. Many lay and professional people were deeply concerned about the state of modern obstetrical care, and in 1978 and 1979 congressional hearings were held on the risks and benefits of common obstetrical interventions, including cesarean sections. The result was a call for a reduction in the rate of cesarean sections and an increase in access to prenatal care. At the same time, the American College of Obstetrics and Gynecologists, the American Academy of Pediatrics, and the American Medical Association approved a resolution against home birth, despite a great deal of scientific evidence backing its safety.

A Renaissance of Midwifery

Laws were revised during the 1970s to regulate and define the practice of midwifery. Although many states were in a political ferment, the percentage of out-of-hospital births more than doubled (from 0.6 percent in 1970 to 1.5 percent in 1977) and was 5 percent or higher in several states, including California and New Mexico.

In the 1980s, normal birth was finally rediscovered in the United States. The Carnegie Foundation reversed its 1910 Flexner Report and encouraged the growth of midwifery care in the United States. It also suggested that midwifery competence could be attained through multiple pathways of learning: for example, through apprenticeship, nursing education, and institutional learning. In 1982, the Midwives Alliance of North America was formed as a group to unify all midwives, regardless of educational background.

At this time, society learned more about natural pregnancy and childbirth. South American obstetrician Roberto Caldeyro-Barcia advocated birth in the upright position, a posture that enhances the natural gravity of the body during birth. As a result, spontaneous pushing rather than "bearing down" during the second stage of labor began to be recommended, and women were encouraged to birth in positions like squatting and on hands and knees. French surgeon Michel Odent made tubs of water available to women during labor and birth, and found that water enhanced relaxation.

A Look Ahead

While much progress has been made in our understanding of a woman's experience of pregnancy and childbirth, over 30 percent of women -- about a million and a half each year -- give birth surgically, and more than 70 percent undergo multiple, unnecessary interventions during childbirth. We can do better than this.

However, more choices are available now than ever before in the arena of pregnancy and childbirth care. Depending upon the state in which she lives, today's mom-to-be can choose a midwife, an obstetrician, a nurse practitioner, a physician's assistant, or a naturopath to assist her during birth.

While pregnancy and birth customs come and go, the questions facing prospective parents are the same as they've always been. What will make me feel well cared for during pregnancy? Where would I feel safest giving birth? Who will I want to be with me? As you ask yourself these questions, realize that the choice is completely yours, and don't be unduly influenced by anyone else.

There's No "Right" Way!

Let's face it: You can do everything "right," eating all the right foods, reading all the books, and talking to all the right practitioners, yet you still can't control your pregnancy or birth. This can lead you to feel personally responsible when things do not proceed as expected. There is no "right way" to give birth. Birth is not a contest. It is a creative process, and as such, every birth is unique. If we give paints, brushes, easels, and canvases to a group of women and ask them to paint the same scene, each painting will be distinctly different -- just as each pregnancy and birth will be a unique experience.

Because each birth is a totally unique and unpredictable event, no amount of preparation or good character can assure a specific result in birth. However, there are some things that have been shown to contribute to a satisfying birth experience: childbirth preparation with a teacher who is independent and not affiliated with any institution or practitioner; suggestions for nondrug pain relief; continuous labor support from another woman; and giving birth in a setting where you feel safe and free from dogmatic beliefs or practices.

This book encourages you to explore drug-free childbirth because nondrug pain relief actually works -- and it offers more of a real sense of control than do drugs. It seems sadly ironic that we protect our bodies from drugs throughout pregnancy, only to flood our bloodstream and our baby's with them during birth. Using drugs during childbirth also raises many questions about both the immediate and long-term effects on mothers and babies.

Birth is a normal event, and no two are alike. There is no single way to prepare all women for childbirth, because birth is unpredictable by nature. Perhaps the best way to prepare yourself for pregnancy and childbirth is to become comfortable with the unexpected. Learn to surrender to things as they are. Rely on your own inner resources, trust your body's responses, and take joy in preparing for the new life that is now becoming a part of yours.

Trusting your body means relying on your body, believing in yourself, and getting to know your own limitations. We often underestimate our body's powerful physical demands. By learning to appreciate your body's natural functions and listening to its needs, you can prepare for the powerful physical focus of birth.

Birth: A Powerful Focus

The news that you're pregnant tends to be accompanied by emotions of joy. Why, then, does the anticipation of birth evoke fear? Our beliefs and attitudes about birth come from stories we heard as children, as well as the experiences of friends and family. We are further shaped by our own birth experiences, by our view of women in general and of women in our own families in particular, as well as by personal, spousal, family, religious and societal beliefs about sex, pregnancy, pain, authority, doctors, midwives, and hospitals.

As you read this book, examine your beliefs and attitudes about each of these words with a friend or with your partner. Doing this will reveal a lot about what you have learned regarding trusting your body during pregnancy and childbirth.

You can develop trust in your body by getting to know yourself in operation. Even though you may be tired intermittently at the beginning of your pregnancy, as your energy returns, you will want to choose a vigorous physical project that engages you. Perhaps you've always wanted to take yoga. Or maybe you set yourself the challenge of walking a bit farther every day. How about getting rid of your inhibitions by regularly dancing around your living room? During my first pregnancy, I chopped down tumbleweeds on our farm. A pregnant friend in Maine helped to dig a shallow well on her property. These physical tasks helped us to focus on our strength, our ability to accomplish new tasks, and our willingness to stretch our physical boundaries.

This is a joyful time in your life -- a time when you may wish to deepen your relationship with the contemplative, spiritual, or sacred. Traditions will also become important to you, as friends welcome your new baby with showers. Recent generations have begun to borrow on indigenous traditions, hosting ritual ceremonies such as Blessingways to honor the pregnant woman. These ceremonies invite the larger community to support you and your family.

Consider keeping a dream or reflective journal during your pregnancy. Record thoughts about your growing baby, as well as your reactions to classic or religious images of mother and child.

Your pregnancy and birth experiences mirror your life. They are peak experiences and can be intense microcosms of some of your unfinished business. It would be unrealistic to expect to transform all aspects of your life during pregnancy. However, such things as exploring attitudes and beliefs about pregnancy and birth will deepen your relationship with both.

And don't forget to balance your serious, thoughtful preparation with play! Make time in your life for experiences that allow you to play, sing, dance, and laugh as much as possible.

This Book

Drawing from the material published in Mothering magazine, along with the most cutting-edge information available, this book outlines the full spectrum of choices available during your pregnancy and childbirth. It is divided into seven parts that follow the sequence of pregnancy, labor, delivery, and the time after the baby is born.

• Part One: The First Trimester (chapters 1 through 3). This section addresses adjusting to pregnancy, making time for yourself, and natural remedies for common concerns of the first three months. An extensive chapter on diet includes cooking, shopping, and menu tips for vegetarians, vegans, and meat eaters, as well as current recommendations regarding nutritional supplements during pregnancy. Part 1 ends with detailed information on choosing your place of birth and birth attendant. We put this right up front because these choices will influence everything that follows in your pregnancy.

• Part Two: The Second Trimester (chapters 4 through 9). By your second trimester, you will be reflecting more deeply on your pregnancy; this section offers some guidance in self-reflection and self-awareness during pregnancy. You will have to make choices during this trimester regarding prenatal testing, and this chapter provides an overview of the most current practices. In this section, good labor support is strongly recommended. You'll learn how to find it, as well as excellent childbirth preparation. To guide your choices, you'll find objective data on mother-friendly birth care. This section ends with information about children attending the birth of a sibling, as well as a discussion about breastfeeding.

• Part Three: The Third Trimester (chapters 10 through 14). This section delves deeper into preparing for your baby's birth. Here you'll be encouraged to reevaluate the birth choices of your first trimester to see if they still suit you. You'll find straight talk about fear and pain in labor, and strategies for avoiding the cascade of medical interventions that often lead to surgical birth. In this section, we suggest some natural means of induction for when it's truly needed, and some practical tips for getting ready for baby.

• Part Four: Labor and Delivery (chapters 15 through 20). In this section, you will find birth stories that show the unique and individual nature of birth. The section provides help for early labor and again revisits your birth intentions. A variety of birth positions are offered, and unnecessary medical interventions such as electronic fetal monitors and episiotomies are discussed.

• Part Five: Postpartum (chapters 21 through 26). The postpartum period is often ignored or given little coverage in books about pregnancy and childbirth. This book provides an extensive chapter on taking care of yourself as a new mother, in addition to getting to know your beautiful new baby. A breastfeeding review is included, as well as a look at how a new baby can affect your marriage or relationship. Honest information on postpartum realities is provided, as well as help for mothers who suffer from postpartum depression. The section ends with helpful suggestions for addressing the dilemma of work and motherhood.

• Part Six: Special Circumstances (chapters 27 through 29). This section offers support for those who find themselves in special circumstances -- sometimes unexpectedly -- during their pregnancies and births. A comprehensive chapter on miscarriage and stillbirth, and one on premature babies, is included, as well as information on other special considerations.

• Part Seven: Just for Fathers (chapters 30 through 32). This chapter provides an overview of important issues, including learning to be a father, fathers at birth, balancing work and family, breastfeeding and sexuality, and sharing household tasks.

Each of the thirty-two chapters will also include three short, easy-to-read sidebars:

Higher Ground: Affirmations, inspirational quotes, and poetry for pregnancy and birth, as well as suggestions for spiritual practices such as meditation, and rituals including Blessingways.

In addition, you'll find these invaluable resources at the end of the book:

• A one-of-a-kind "Birth Report Card" that will allow you to evaluate the practitioners you are considering according to the standards of the World Health Organization, the Coalition for Improving Maternity Services, and the national averages.

• An exhaustive resource list that is regularly updated on the magazine's Web site: www.mothering.com.

This book is for you if you want real informed consent. Do you want to read extensively about pregnancy and birth, participate fully in decision making, and make educated, personal choices from the full range of options available? Do you have faith in a time-tested, nonmedical approach to birth that is proven safe and that offers nondrug pain reduction techniques? Read on to learn how you can make the best possible choices to protect your new baby's health.

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Introduction: In the Beginning

Congratulations! You're pregnant. You are now wondering how to create the best possible environment for you and your baby, and the environment that you have the most control over is your mental one. It is important that you have a good inner opinion of yourself during pregnancy. Rest assured that your body is already equipped for the challenges of pregnancy and birth. You can educate your mind, develop trust in your body, and fortify your spirit with accurate and objective information. And you can trust yourself to act in your own best interests and in the best interests of your child.

With pregnancy, you may be surprised to find how deeply your choices have been influenced by the beliefs, attitudes, and customs of society, by the opinions of family members, and by your general lack of exposure to birth. Unless you have witnessed them, pregnancy and birth can seem strange and frightening when in fact they are simple and natural. Several factors contribute to our collective belief that pregnancy and birth are complicated. The overmedicalization of childbirth in the United States, the human tendency to be intimidated by custom and authority, and the fact that insurance companies often only cover hospital birth make real choices in childbirth difficult if not impossible.

In 1982 psychiatrist Ronald Laing wrote, "We do not see childbirth in many obstetric units now. What we see resembles childbirth as much as artificial insemination resembles sexual intercourse. And, birth, as a home and family event, has virtually been cultured out." Laing believed this change was a matter of power. "Women are allowed or not to have their babies at home. In hospital, they are allowed or not to move, scream or sing, stand, walk, sit or squat. Women are allowed or not to have their babies after birth....To allow is to exercise as much, if not more power, than to forbid." Laing pleaded for genuine choice, asking, "Why should any one way have to be imposed on all? Why cannot two or more ways coexist in the same society? Why should there be any monopoly on what is available?"

Understanding Your Choices: Informed Consent

Pregnancy and birth are normal biological events. They are not medical events, but they take place within a cultural context and are colored by the beliefs and attitudes of the community at large. Hopefully, this book will give you a bigger sense of these events as they occur in this larger community, and help you to find the information and support you need to plan for your own birth environment and the arrival of your new baby.

You deserve to have true informed consent regarding the decisions you make during this time. While it sounds like a fancy term, informed consent simply means that you have the right to know the risks and benefits of treatment, and the right to choose which procedures you want during pregnancy and birth, regardless of how commonly they are used. All too often, we undergo procedures passively, without being aware that we could question or even decline a treatment.

Informed consent has been a legal principle for 100 years in the United States. This doctrine requires practitioners to disclose all information needed to make a decision, and requires that consent be given voluntarily and without coercion. The concept of informed consent is critical: in thousands of letters to Mothering magazine, women have said that they regret that they had not known more about their choices during pregnancy and birth.

The advice and suggestions in this book are based not only on scientific evidence but on the experiences of these women who have come to trust Mothering magazine as a respected authority on natural family living.

About Our Sources

Mothers-to-be are often confused by the conflicting medical literature that is available. For example, guests on talk shows routinely quote contradictory findings to prove a specific point. In addition, practices in common use are not always supported by medical research. As a pregnant woman, you will want to look carefully at the evidence, so I have sought out a definitive and objective resource.

The recommendations in this book are based on Oxford University's Effective Care in Pregnancy and Childbirth, a 1,500-page, two-volume book that summarizes the most authoritative international studies available on the effects of care practices during pregnancy, during childbirth, and after the baby is born. The first edition, published in 1989, was widely acclaimed as a landmark publication. For the first time, evidence-based information on the effects of pregnancy and childbirth care was made readable and accessible to all who needed and wanted it.

The second edition won first prize in the British Medical Association 1995 Medical Book Competition in the Primary Health Care category, and has been translated into several languages. The third edition of this book was prepared by the editors of the Cochrane Pregnancy and Childbirth Group, along with Murray W. Enkin, M.D., a prominent physician and author of the first edition.

Effective Care in Pregnancy and Childbirth has been compiled into an electronic database consisting of a register of over 9,000 controlled studies from almost 400 medical journals, in 18 different languages, from 85 different countries -- as well as a systematic review of their results. The suggestions here are based on the latest, most comprehensive scientific evidence, providing you with the most up-to-date information on which to compare choices for yourself during pregnancy and childbirth.

Why Natural?

As the title implies, this book focuses on natural pregnancy and childbirth, subjects Mothering magazine has been reporting on for over twenty-five years. During that time, we've learned that women who experience natural childbirth not only report greater satisfaction with their birth experiences than those who do not, but also feel less pain and discomfort during the early weeks and months of motherhood. It is unfortunate, therefore, that these concepts have been misunderstood in recent years. For instance, some consider a birth "natural" simply if the mother is conscious, while others, more accurately, understand that a natural childbirth is a drug-free birth. Even more unfortunate is the fact that so few women are helped and encouraged to have a natural birth.

You may be frightened when the subject turns to drugs in labor and wonder if natural birth means that your choices will be limited. Some of you would hate to have drugs foisted on you; others want to make sure that you have access to the comfort level of your choice. In pregnancy and birth, what you want is simply choice. And yet you may not realize how much your choices are limited by the constructed culture of birth, by custom unsupported by evidence, and by our general lack of exposure to and discomfort with birth. For example, most women will experience ultrasound scans during their pregnancies, even though ultrasound is not recommended for routine use by the American College of Obstetricians and Gynecologists. Electronic fetal monitors are routinely used in hospital birth, yet they have never been shown in scientific studies to be any more effective than a simple stethoscope. And it may surprise you to learn that birth is safe in any setting -- home, hospital, birth center -- although only 1 percent of births in the United States take place outside of a hospital.

Twenty-three other countries have better birth outcomes than we do in the United States. All of these countries spend less money on health care than we do. Even with all of our technology, we are not protecting as many babies and mothers as other countries do with less. American insurance companies define pregnancy as a disability; obstetrical medicine acts defensively to ward off malpractice suits; pharmaceutical companies and manufacturers of birth technology entice practitioners to try their products by offering incentives; in short, as a culture, we are uncomfortable with the intimate physical events of pregnancy, birth, and breastfeeding.

What do those twenty-three countries have in common -- those who spend less money yet have better birth outcomes than the United States? All of them rely on midwives. In New Zealand, for example, midwives attend 70 percent of births. In the United States, midwives attend nearly 10 percent of births.

Compare these labor and delivery outcomes for low-risk mothers who were clients of certified nurse-midwives (CNMs) with the clients of physicians (M.D.s):

Labor and Delivery ProcedureCNMsM.D.s

Oxytocin induction* 8.5% 15.2%

Oxytocin augmentation** 11.7% 37.2%

Internal electronic fetal monitor 16.2% 43.5%

Epidural anesthesia 17.3% 32.7%

Episiotomies 10.8% 35.4%

Third- and fourth-degree lacerations*** 6.6% 23.3%

Operative deliveries**** 11.0% 30.1%

* Oxytocin induction is the use of the drug oxytocin to attempt to end pregnancy and stimulate labor to begin.

** Oxytocin augmentation is the use of oxytocin to attempt to increase the strength or effectiveness of labor contractions.

*** Third- and fourth-degree lacerations are tears of the perineum, usually following an episiotomy, that extend into the rectum.

**** Operative deliveries include those delivered by vacuum extraction, forceps, or cesarean section

The Institutes of Medicine, the Office of Technology Assessment of the U.S. Congress, and the National Commission to Prevent Infant Mortality have all published statements of support for the development of nurse midwifery in the United States. In 1989, the National Birth Center Study was published in the New England Journal of Medicine, a study that demonstrated positive results of care of 12,000 birthing women by certified nurse midwives. The study showed that compared to hospital births, birth center births had a lower risk of cesareans, less infant death, and no maternal death.

More Evidence for Natural Birth

In her 1990 book Safer Childbirth, British statistician Marjorie Tew published overwhelming evidence for the safety and superiority of skillful midwifery and home birth. In fact, no study of matched populations has ever shown home birth to be unsafe.

In a report published in March 1992, the British House of Commons stated, "We conclude that the choices of a homebirth or birth in small maternity units are options which have been substantially withdrawn from the majority of women in this country....The policy of encouraging all women to give birth in hospitals cannot be justified on the grounds of safety....Hospitals are not the appropriate place to care for healthy women."

A 1998 National Institutes of Health study published in the Journal of Epidemiology and Community Health found that patients of certified nurse midwives have 19 percent lower infant mortality rates than doctors, 31 percent less neonatal mortality, and 33 percent less incidence of low birth weight.

A 1999 Stanford University dissertation by Peter F. Schlenzka provided even more evidence of the safety of natural childbirth. He examined nearly 816,000 births from 1989 and 1990, comparing both low-risk and high-risk births occurring both at home and at the hospital. Schlenzka found no difference in mortality rates for infants born in the hospital or in other settings. His findings clearly show that the natural approach is as safe for both groups.

In California, Santa Cruz County has cited Schlenzka's research as the basis for ballot initiatives calling for expanded birth services for local residents. The county's December 2000 Strategic Plan called for adopting the goals of the "Mother Friendly Childbirth Initiative," a document defining ten prerequisites for a mother-friendly birthing environment; making midwifery care available at the local hospital; providing every pregnant woman with a "Midwifery Model of Care" brochure; funding development of a freestanding birth center; ensuring financial support for women who desire out-of-hospital birth; and awarding grants to helping services and nonprofits. These initiatives are significant because they mark the first time a county government has recommendedalternatives to hospital birth.

The History of Childbirth

If midwifery care and natural birth are actually safer and more satisfying, why are they not more popular? To answer this question, it is important to understand the cultural context, which determines to a large extent both our choices and our experiences regarding pregnancy and childbirth. For nearly 200 years, midwives, physicians, and nurses have competed in one way or another to be the main care providers for pregnant and birthing women. The enduring influences of this competition have affected our choices regarding place of birth, birth attendant, birth interventions, and pain management, as well as physical contact with our babies, breastfeeding, postpartum care, and early family life.

Early Midwives and Obstetricians

Not until the Revolutionary War did educated doctors seek to attend births. Before then, physicians regarded care of the pregnant woman as beneath their dignity and expertise. In addition, childbirth was viewed as a life-threatening event that could result in death, regardless of who attended the birth. Midwifery was not considered part of medicine, and the few men who did attempt to practice midwifery were widely ridiculed for their intrusion into an exclusively female profession. Midwives were generally women who had birthed several of their own children, and had learned by assisting at friends' births or learning from an established midwife. Organized training programs and schools for midwives did not exist until 1848, when the Boston Female Medical College opened in the United States.

Midwives were often the only source of health care, and they were respected members of the community. Many came as colonists, some as slaves, and others as immigrants. While some had received training in other countries, learning was most often passed on through the apprenticeship method, and yet most midwives were isolated from one another, busy with their own families, and did not think of themselves as members of a profession.

With the development of obstetrical forceps in the 1750s in England, obstetrical practices began to change rather dramatically, both in England and subsequently in the United States. Midwives who had maintained an unquestioned monopoly found themselves in competition with male practitioners -- now claiming to have superior knowledge in the form of obstetrical instruments.

At first, physicians were only called to assist at difficult births, but gradually it became more common for forceps to be used to hasten the process of normal delivery. By the early 1800s, it was popular for upper- and middle-class women to have forceps deliveries with male physicians.

By the mid-1800s, medicine was becoming professionalized: the American Medical Association, founded in 1847, recognized obstetrics as one of its four special sections as early as 1859. By 1888, the American Association of Obstetricians and Gynecologists was formed. Physicians sought legislation that would create state licensing requirements allowing only physicians to practice medicine.

Unfortunately, there was no effort at that time to educate and license midwives. Midwifery practices were diverse, and laws were mainly local. In fact, it was not until the 1920s that most midwives practiced under some type of regulation. By that time, there were not enough schools to certify professional midwives in sufficient numbers.

By 1900, physicians were attending about 50 percent of all births in the United States, and virtually 100 percent of the births of middle- and upper-class women. Midwives primarily took care of poor women. At this time, misguided advocates for women, including female physicians, male obstetricians, and others, demanded the abolition of midwifery, claiming that it was unsafe. They called for the prohibition of midwives, especially in areas where doctors were available.

In the years to come, midwives were systematically outlawed as state after state succumbed to intense medical pressure. Meanwhile, in England, Germany and most European nations, midwives were trained to become established and independent practitioners.

The Rise of Medical Birth

The struggle between midwife and physician for dominance in the care of pregnant and birthing women peaked between 1910 and 1935. The Carnegie Foundation's 1910 Flexner Report focused on medical education in the United States in general and found it to be of poor overall quality, with obstetrics making the worst showing. The report concluded that medical progress required obstetric physicians to take over the supervision of childbirth, adding that there was not enough time to educate and certify midwives.

The prejudices of the time supported this view, and the most influential obstetricians publicly participated in the defamation of midwives as untrained and therefore unsafe. The 50 percent of births still attended by midwives were seen as a missed opportunity for obstetrical training.

In addition, experts of the early 1900s argued that childbirth was a dangerous condition that damaged most women and warranted routine medical intervention. In fact, they believed that forceps delivery was safer than unassisted labor, which was assumed to hinder a woman's sexual functioning and possibly damage her baby's brain. The campaign to eliminate midwives was part of the attempt by obstetricians to establish the credibility of their own fledgling profession.

The 1900s saw the beginning of the American migration to cities, the development of the modern hospital, and the rise of allopathic, or Western, medicine. By 1939, the use of sterile techniques and the development of antibiotics improved the safety of birth, particularly in hospitals, where infections after childbirth were common.

In addition, economic factors made hospital birth more acceptable. Prior to the 1930s, individuals paid for all of their own medical expenses. The Great Depression spurred the creation, in 1943, of the Emergency Maternity and Infant Care (EMIC) program, which eventually provided free hospital obstetric care to over a million mothers and babies. Within three years, it covered one of every seven births in the United States, and therefore made hospital birth affordable. By the late 1940s, half of all births took place in the hospital.

In the 1940s, the "modern way" to give birth was under total anesthesia. "Twilight sleep," the method of choice, involved injecting a laboring woman with morphine and then giving her the amnesiac, or memory-impairing, drug scopolamine. At the time, the development of twilight sleep was hailed as a breakthrough, although the birthing woman was so drugged that she could seldom participate in the birth, requiring multiple interventions such as episiotomies and forceps delivery.

By 1960, nearly all women gave birth in the hospital. Over 90 percent of white women and 74 percent of African-American women were anesthetized during delivery. Eventually it was recognized that morphine contributed to maternal deaths, that scopolamine didn't actually kill pain (only the memory of pain), and that general anesthesia depressed the mother's as well as the baby's respiratory and nervous system. Sadly, home birth had virtually been eradicated by the mid-1970s, and 99 percent of births took place in the hospital.

Natural Childbirth Is Reborn

Counter to this increased medicalization of childbirth were two breakthroughs. One was the 1944 publication of Grantly Dick-Read's book Childbirth without Fear: The Principles and Practice of Natural Childbirth, a book that discussed for the first time in the popular press the role that emotions play in birth. Dick-Read, a British obstetrician, proposed the then-novel idea that fearing the pain of labor increases the pain of labor. Dick-Read concluded that educating women about childbirth could prepare them to withstand its rigors. Dick-Read became the first to advocate the use of controlled breathing and relaxation techniques during labor. Results with the Dick-Read method at Yale New Haven Hospital Clinic in 1946 showed that women who were educated in breathing and relaxation techniques used less medication than unprepared women.

The second breakthrough came in 1951 when two French obstetricians, Fernand Lamaze and Pierre Vellay, traveled to Russia to observe the so-called psychoprophylactic (mind-over-matter) obstetrical practices in use there. In 1956 Painless Childbirth, Lamaze's classic book on this practice, was published. His method relied heavily on the use of distraction techniques during contractions. The most famous of these techniques involves structured, controlled breathing.

In 1960 Elisabeth Bing, a physical therapist, and Marjorie Karmel, a mother who had trained with Dr. Lamaze while pregnant in France, introduced and popularized this technique as "the Lamaze method" in the United States.

Significant Strides

Meanwhile, despite persecution from obstetricians, midwifery care continued to evolve. In 1911, amid studies that concluded that mothers and babies in the United States were dying more often than they were in many western European countries, the commissioner of health for New York City criticized the United States as being the only "civilized" country in the world that did not safeguard the care of mothers and babies by training and regulating midwives.

In 1918 the Maternity Center Association, the first woman-centered birthing organization in the United States, created the nation's first prenatal-care pilot project, as well as another significant first -- classes for expectant parents. A report on the association's first twenty years of operation appeared in 1955 in the American Journal of Obstetrics and Gynecology. Of 5,000 births attended by association midwives, 87 percent took place in the home. Women cared for by these midwives were nearly three times less likely to die in childbirth than the average woman, who typically gave birth in a hospital setting without a midwife present.

In 1925 Mary Breckenridge, a British-trained midwife, established the Frontier Nursing Service in the Appalachian Mountains of southeastern Kentucky, creating a new model for rural health care and sowing the seeds of nurse-midwifery. Sixteen graduates of the Frontier Nursing Service formed the first nurse-midwifery organization in the United States, the Kentucky Association of Midwives, in 1929. This group went on to become the American Association of Nurse-Midwives, originally affiliated with the National Organization for Public Health Nursing, and later established as the American College of Nurse-Midwives.

Voices of a New Generation

In the 1960s the voices of pregnant and birthing women began to be heard. In 1960, the International Childbirth Education Association was founded to promote family-centered maternity care and freedom of choice based on knowledge of alternatives. Sheila Kitzinger's revolutionary book The Experience of Childbirth, published in 1962, introduced the idea that birth is a highly personal event. She recommended that labor pains be accepted as "pain with a purpose."

In 1965 Robert Bradley, M.D., published Husband Coached Childbirth, adding American innovations to the Dick-Read relaxation and breathing methods. Bradley especially encouraged husbands to participate as coaches during the birth process. It was not until the 1970s, however, that fathers were actually "allowed" in the delivery room with mothers.

Birth activism came of age in the 1970s, with the publication of three landmark books: Doris Haire's Cultural Warping of Childbirth; Suzanne Arms's Immaculate Deception; and Ina May Gaskin's Spiritual Midwifery. In 1976, Mothering magazine was founded as a voice of this activism. The Seattle Midwifery School opened in 1978 as the first modern midwifery school in the United States that did not require a nursing degree for admittance.

That same year the cesarean section rate for the United States hit 18 percent; it was 7 percent in 1960. Many lay and professional people were deeply concerned about the state of modern obstetrical care, and in 1978 and 1979 congressional hearings were held on the risks and benefits of common obstetrical interventions, including cesarean sections. The result was a call for a reduction in the rate of cesarean sections and an increase in access to prenatal care. At the same time, the American College of Obstetrics and Gynecologists, the American Academy of Pediatrics, and the American Medical Association approved a resolution against home birth, despite a great deal of scientific evidence backing its safety.

A Renaissance of Midwifery

Laws were revised during the 1970s to regulate and define the practice of midwifery. Although many states were in a political ferment, the percentage of out-of-hospital births more than doubled (from 0.6 percent in 1970 to 1.5 percent in 1977) and was 5 percent or higher in several states, including California and New Mexico.

In the 1980s, normal birth was finally rediscovered in the United States. The Carnegie Foundation reversed its 1910 Flexner Report and encouraged the growth of midwifery care in the United States. It also suggested that midwifery competence could be attained through multiple pathways of learning: for example, through apprenticeship, nursing education, and institutional learning. In 1982, the Midwives Alliance of North America was formed as a group to unify all midwives, regardless of educational background.

At this time, society learned more about natural pregnancy and childbirth. South American obstetrician Roberto Caldeyro-Barcia advocated birth in the upright position, a posture that enhances the natural gravity of the body during birth. As a result, spontaneous pushing rather than "bearing down" during the second stage of labor began to be recommended, and women were encouraged to birth in positions like squatting and on hands and knees. French surgeon Michel Odent made tubs of water available to women during labor and birth, and found that water enhanced relaxation.

A Look Ahead

While much progress has been made in our understanding of a woman's experience of pregnancy and childbirth, over 30 percent of women -- about a million and a half each year -- give birth surgically, and more than 70 percent undergo multiple, unnecessary interventions during childbirth. We can do better than this.

However, more choices are available now than ever before in the arena of pregnancy and childbirth care. Depending upon the state in which she lives, today's mom-to-be can choose a midwife, an obstetrician, a nurse practitioner, a physician's assistant, or a naturopath to assist her during birth.

While pregnancy and birth customs come and go, the questions facing prospective parents are the same as they've always been. What will make me feel well cared for during pregnancy? Where would I feel safest giving birth? Who will I want to be with me? As you ask yourself these questions, realize that the choice is completely yours, and don't be unduly influenced by anyone else.

There's No "Right" Way!

Let's face it: You can do everything "right," eating all the right foods, reading all the books, and talking to all the right practitioners, yet you still can't control your pregnancy or birth. This can lead you to feel personally responsible when things do not proceed as expected. There is no "right way" to give birth. Birth is not a contest. It is a creative process, and as such, every birth is unique. If we give paints, brushes, easels, and canvases to a group of women and ask them to paint the same scene, each painting will be distinctly different -- just as each pregnancy and birth will be a unique experience.

Because each birth is a totally unique and unpredictable event, no amount of preparation or good character can assure a specific result in birth. However, there are some things that have been shown to contribute to a satisfying birth experience: childbirth preparation with a teacher who is independent and not affiliated with any institution or practitioner; suggestions for nondrug pain relief; continuous labor support from another woman; and giving birth in a setting where you feel safe and free from dogmatic beliefs or practices.

This book encourages you to explore drug-free childbirth because nondrug pain relief actually works -- and it offers more of a real sense of control than do drugs. It seems sadly ironic that we protect our bodies from drugs throughout pregnancy, only to flood our bloodstream and our baby's with them during birth. Using drugs during childbirth also raises many questions about both the immediate and long-term effects on mothers and babies.

Birth is a normal event, and no two are alike. There is no single way to prepare all women for childbirth, because birth is unpredictable by nature. Perhaps the best way to prepare yourself for pregnancy and childbirth is to become comfortable with the unexpected. Learn to surrender to things as they are. Rely on your own inner resources, trust your body's responses, and take joy in preparing for the new life that is now becoming a part of yours.

Trusting your body means relying on your body, believing in yourself, and getting to know your own limitations. We often underestimate our body's powerful physical demands. By learning to appreciate your body's natural functions and listening to its needs, you can prepare for the powerful physical focus of birth.

Birth: A Powerful Focus

The news that you're pregnant tends to be accompanied by emotions of joy. Why, then, does the anticipation of birth evoke fear? Our beliefs and attitudes about birth come from stories we heard as children, as well as the experiences of friends and family. We are further shaped by our own birth experiences, by our view of women in general and of women in our own families in particular, as well as by personal, spousal, family, religious and societal beliefs about sex, pregnancy, pain, authority, doctors, midwives, and hospitals.

As you read this book, examine your beliefs and attitudes about each of these words with a friend or with your partner. Doing this will reveal a lot about what you have learned regarding trusting your body during pregnancy and childbirth.

You can develop trust in your body by getting to know yourself in operation. Even though you may be tired intermittently at the beginning of your pregnancy, as your energy returns, you will want to choose a vigorous physical project that engages you. Perhaps you've always wanted to take yoga. Or maybe you set yourself the challenge of walking a bit farther every day. How about getting rid of your inhibitions by regularly dancing around your living room? During my first pregnancy, I chopped down tumbleweeds on our farm. A pregnant friend in Maine helped to dig a shallow well on her property. These physical tasks helped us to focus on our strength, our ability to accomplish new tasks, and our willingness to stretch our physical boundaries.

This is a joyful time in your life -- a time when you may wish to deepen your relationship with the contemplative, spiritual, or sacred. Traditions will also become important to you, as friends welcome your new baby with showers. Recent generations have begun to borrow on indigenous traditions, hosting ritual ceremonies such as Blessingways to honor the pregnant woman. These ceremonies invite the larger community to support you and your family.

Consider keeping a dream or reflective journal during your pregnancy. Record thoughts about your growing baby, as well as your reactions to classic or religious images of mother and child.

Your pregnancy and birth experiences mirror your life. They are peak experiences and can be intense microcosms of some of your unfinished business. It would be unrealistic to expect to transform all aspects of your life during pregnancy. However, such things as exploring attitudes and beliefs about pregnancy and birth will deepen your relationship with both.

And don't forget to balance your serious, thoughtful preparation with play! Make time in your life for experiences that allow you to play, sing, dance, and laugh as much as possible.

This Book

Drawing from the material published in Mothering magazine, along with the most cutting-edge information available, this book outlines the full spectrum of choices available during your pregnancy and childbirth. It is divided into seven parts that follow the sequence of pregnancy, labor, delivery, and the time after the baby is born.

• Part One: The First Trimester (chapters 1 through 3). This section addresses adjusting to pregnancy, making time for yourself, and natural remedies for common concerns of the first three months. An extensive chapter on diet includes cooking, shopping, and menu tips for vegetarians, vegans, and meat eaters, as well as current recommendations regarding nutritional supplements during pregnancy. Part 1 ends with detailed information on choosing your place of birth and birth attendant. We put this right up front because these choices will influence everything that follows in your pregnancy.

• Part Two: The Second Trimester (chapters 4 through 9). By your second trimester, you will be reflecting more deeply on your pregnancy; this section offers some guidance in self-reflection and self-awareness during pregnancy. You will have to make choices during this trimester regarding prenatal testing, and this chapter provides an overview of the most current practices. In this section, good labor support is strongly recommended. You'll learn how to find it, as well as excellent childbirth preparation. To guide your choices, you'll find objective data on mother-friendly birth care. This section ends with information about children attending the birth of a sibling, as well as a discussion about breastfeeding.

• Part Three: The Third Trimester (chapters 10 through 14). This section delves deeper into preparing for your baby's birth. Here you'll be encouraged to reevaluate the birth choices of your first trimester to see if they still suit you. You'll find straight talk about fear and pain in labor, and strategies for avoiding the cascade of medical interventions that often lead to surgical birth. In this section, we suggest some natural means of induction for when it's truly needed, and some practical tips for getting ready for baby.

• Part Four: Labor and Delivery (chapters 15 through 20). In this section, you will find birth stories that show the unique and individual nature of birth. The section provides help for early labor and again revisits your birth intentions. A variety of birth positions are offered, and unnecessary medical interventions such as electronic fetal monitors and episiotomies are discussed.

• Part Five: Postpartum (chapters 21 through 26). The postpartum period is often ignored or given little coverage in books about pregnancy and childbirth. This book provides an extensive chapter on taking care of yourself as a new mother, in addition to getting to know your beautiful new baby. A breastfeeding review is included, as well as a look at how a new baby can affect your marriage or relationship. Honest information on postpartum realities is provided, as well as help for mothers who suffer from postpartum depression. The section ends with helpful suggestions for addressing the dilemma of work and motherhood.

• Part Six: Special Circumstances (chapters 27 through 29). This section offers support for those who find themselves in special circumstances -- sometimes unexpectedly -- during their pregnancies and births. A comprehensive chapter on miscarriage and stillbirth, and one on premature babies, is included, as well as information on other special considerations.

• Part Seven: Just for Fathers (chapters 30 through 32). This chapter provides an overview of important issues, including learning to be a father, fathers at birth, balancing work and family, breastfeeding and sexuality, and sharing household tasks.

Each of the thirty-two chapters will also include three short, easy-to-read sidebars:

Higher Ground: Affirmations, inspirational quotes, and poetry for pregnancy and birth, as well as suggestions for spiritual practices such as meditation, and rituals including Blessingways.

In addition, you'll find these invaluable resources at the end of the book:

• A one-of-a-kind "Birth Report Card" that will allow you to evaluate the practitioners you are considering according to the standards of the World Health Organization, the Coalition for Improving Maternity Services, and the national averages.

• An exhaustive resource list that is regularly updated on the magazine's Web site: www.mothering.com.

This book is for you if you want real informed consent. Do you want to read extensively about pregnancy and birth, participate fully in decision making, and make educated, personal choices from the full range of options available? Do you have faith in a time-tested, nonmedical approach to birth that is proven safe and that offers nondrug pain reduction techniques? Read on to learn how you can make the best possible choices to protect your new baby's health.

The Mothering Magazine Guide to Pregnancy and Childbirth

Mothering Magazine's Having a Baby, Naturally

The Mothering Magazine Guide to Pregnancy and Childbirth

For more than twenty-five years, Mothering magazine has captured an audience of educated women who appreciate its "we'll inform, you choose" approach to parenting. Having a Baby, Naturally reflects this spirit with straightforward, uncensored information about pregnancy and childbirth, addressing common concerns and questions in a compassionate, nonjudgmental style.

Written by Peggy O'Mara, the longtime publisher, editor, and owner of Mothering magazine, it synthesizes the best theories and safest practices used in natural childbirth, including recommendations from the World Health Organization, the American Academy of Pediatrics, and the American College of Obstetricians and Gynecologists. Throughout, O'Mara reinforces her belief that each woman's pregnancy and birth experience is a one-of-a-kind event. She covers such topics as:

Nutrition, diet, and exercise

Emotional self-awareness during and after pregnancy

A trimester-by-trimester guide to what is happening in your body and your child's

Birth choices -- offering suggestions, not "rules"

Pain medication alternatives

Birth locations, from hospitals to home birth

Relieving morning sickness with natural remedies

Prenatal testing

Breastfeeding

Prematurity and multiple births

Balancing work and family

The father's role during pregnancy and beyond

Difficult subjects, such as birth defects, miscarriages, and postpartum depression, are also treated with sensitivity and candor.

Finally, a book for the thinking woman who believes in her own inherent capacity to make smart, informed decisions about her pregnancy and birth, just as she makes in other areas of her life. Having a Baby, Naturally is a celebration of childbirth and an accurate and objective guide to helping women fortify their spirits, develop trust in their bodies, and make the best possible choices to protect their new baby's health.